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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTheApplication. <br /> FOI;OFFICE USE: APPLIC_ATiON � <br /> (For Non-Transferable, Revocable,Suspendabte) / PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN IPLIGATE} WATER QUALITY . . <br /> ,�:, Wit. � ' <br /> Application is hereby made to the San Joaquin Local Health District for a perrriitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance o. 1862 and the rules and regulations of the San Joaquin Loca'Heal lh Distncf..x. . <br /> w 1� - '+s Clty/Town <br /> Exact Site Address <br /> AJYZ tf° Phoney <br /> Owner's'Name <br /> Address 4y <br /> Contractor's Name mVS7 c > icefte Business-Phone- <br /> Contractor's Address _�� <br /> s`�llX°° p - Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ fJESTRCICTION —_ <br /> WELL CHLORINATION 11WELL ABANDONMENT 13 -OTHER 0 PUMP,INSTALLATION E3PUMP REPAIR❑ <br /> I REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field. - I Cesspool/Seepage Pit Other <br /> Property Line Private Domestic Well Public Domestic Well <br /> 8 INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL 13 CABLE TOOL Dia. of Well Excavation ; <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ' <br /> ❑ DOMESTIC/PUBiLIC <br /> 11DRIVEN Gauge of Casing <br /> i ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal ' <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout } <br /> ❑ DISPOSAL ❑ OTHER Other Information { <br /> 11 GEOPHYSICAL Surface Seal Installed By: <br /> I 3 <br /> PUMP INSTALLATION: Contractor k <br /> Type of Pump H'P } ti <br /> i PUMP REPLACEMENT: <br /> ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done t <br /> I DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> I I 7 Ad <br /> Describe Material and.Procedure <br /> $ '- <br /> I hereby certify that I have prepared-this application and-that the work will be dynein accordance wwiteSan,Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local HealthtDistrict. <br /> F Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued,•1 shall not employ any person �n such manner as to become subject to Vaorkman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifies the following:"I certify that in the performance of the work forswhich this <br /> permit is issued, 1 shall employ, persons subject to workman's compensation-lavvs�of California." ?� ( z <br /> I, I wil all for a Grout inspection`prier'to-grouting and a final inspection. <br /> ' <br /> Title,. Datei <br /> Signed X <br /> (Draw Plat Plan on Reverse Side)f <br /> I _ I <br /> i I FOR DEPARTMENT USE ONLY 1 i <br /> PHASE Ijt <br /> Application Accepted By F <br /> Da e- <br /> Additional Comments: <br /> i Phase III Grout Inspection €i P s fl Final Inspection <br /> I - Inspection By; ) Date + <br /> r <br /> Inspection!By Date i i <br /> t <br /> Fee Is Due: C1jANNUALLY ❑'PER UNIT <br /> El PER SITE -0 EACH ❑ J nuary 1 8 Received By Janvary 31 ❑ July 1 8 Received By July 31 <br /> �...,.:.•__...,�—..�....-....;.�_,_._L...-� �..,.._—'�'---'•w--._.--------t-_."�.'<.. �-. .REMIT--r <br /> _ 'BILLING. - REMITTANCE _. $ AMDUNF-DUE CHECKED <br /> �+ BASE - EXPLANATION DATE DATE .REMITTED AMOUNT . <br /> FEE - <br /> LESS <br /> PRORATION <br /> PLUS �'- <br /> } PENALTY <br /> OTHER <br /> OTHER - <br /> t <br /> Date Receipt No. Permit.No. Issuance Date' Mailed DeVvered <br /> -Received Eby._ - y' -- . <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CA 95201 <br />